Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Accidental hypothermia following exposure to cold weather.
Accidental hypothermia discovered during a routine evaluation.
Follow-up visit for a patient previously treated for hypothermia.
History of Present Illness (HPI)
Describe the circumstances leading to the suspected or confirmed hypothermia.
Include details about:
Duration of cold exposure
Environmental conditions (wind chill, water immersion)
Clothing worn
Activity level
Witnessed behavior changes (confusion, slurred speech)
Mention any initial symptoms reported by the patient or witnesses, such as:
Shivering
Clumsiness
Confusion
Slurred speech
Drowsiness
Past Medical History (PMHx)
Briefly mention any relevant past medical history that may increase susceptibility to hypothermia, such as:
Hypothyroidism
Diabetes
Malnutrition
Alcohol or substance abuse
Peripheral vascular disease
Previous episodes of hypothermia
Medications
List all current medications the patient is taking.
Some medications, like beta-blockers, can alter the body’s thermoregulatory response.
Social History (SHx)
Include relevant social history that may have contributed to the hypothermia event, such as:
Alcohol or substance use
Homelessness
Mental health conditions
Physical Examination
General: Assess overall health, appearance, and level of consciousness.
Vital Signs:
Document core body temperature (rectal is preferred).
Also note blood pressure, heart rate, respiratory rate, and oxygen saturation.
Skin: Assess for pallor, cyanosis (bluish discoloration), and presence of shivering.
Neurological: Evaluate mental status for confusion, drowsiness, or slurred speech.
Assessment
Summarize the key findings from the history and physical examination.
State the core body temperature and classify the severity of hypothermia based on established criteria (e.g., mild, moderate, severe).
Briefly discuss the potential complications of hypothermia, such as cardiac arrhythmias, electrolyte imbalances, and organ dysfunction.
Plan
Outline the next steps in the patient’s management. This may include:
Initial Resuscitation:
Focus on rewarming the core body temperature gradually using appropriate methods (e.g., warm blankets, forced-air warming).
Avoid rapid rewarming to prevent complications like rewarming shock.
Fluid Resuscitation:
Administer intravenous fluids to address dehydration and electrolyte imbalances.
Cardiac Monitoring:
Closely monitor vital signs and heart rhythm for potential complications.
Blood Tests:
Check electrolytes, blood sugar, and other tests as indicated to assess for organ function and identify potential complications.
Supportive Care:
Provide supportive measures like pain management and monitoring for infection.
Disposition:
Determine the appropriate disposition based on the severity of hypothermia and response to treatment.
The patient may require hospitalization for further monitoring and treatment or may be discharged home with close follow-up.
Patient Education:
Educate the patient about the risks of hypothermia and preventive measures, especially if susceptibility factors are present.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, ongoing management, follow-up visit).
Use clear and concise language while maintaining medical accuracy.
Document the time core body temperature reaches normothermic range (normal body temperature).
Document any discussions or shared decision-making with the patient regarding the plan.
This template provides a framework for documenting progress notes for patients with accidental hypothermia. Remember to tailor it to your specific workflow and facility’s documentation standards.